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MAP target for older adults with septic shock (February 2020)
Previous studies in older adults with septic shock suggest that a mean arterial pressure (MAP) lower than the traditional target of ≥65 mmHg may have a mortality benefit. In an unblinded, randomized trial of 2600 older patients with vasodilatory shock (septic shock in 80 percent), 90-day mortality was 41 percent for individuals who received vasopressors at a MAP target of 60 to 65 mmHg ("permissive hypotension," mean achieved MAP 67 mmHg) compared with 44 percent for patients who received usual care (mean achieved MAP 73 mmHg), although this difference was not significant. Adjusted analysis suggested a significant mortality benefit for the lower MAP target. Adverse outcomes, including acute kidney injury and supraventricular arrhythmias, were similar in both groups. These findings support the safety of a lower MAP target in older patients with septic shock but are inconclusive regarding a mortality benefit. We continue to support a target MAP within a range of 60 to 70 mmHg that is individualized for such patients.
All patients should be followed clinically for improved mean arterial pressure (MAP), urine output, heart rate, respiratory rate, skin color, temperature, pulse oximetry, and mental status. Among these, a MAP ≥65 mmHg (MAP = [(2 x diastolic) + systolic]/3), and urine output ≥0.5 mL/kg per hour are common targets used in clinical practice. They have not been compared to each other nor have they been proven to be superior to any other target or to clinical assessment.
Most clinicians target a MAP ≥65 mmHg based upon data from large randomized trials that demonstrated benefit when using this target MAP. However, the ideal target for MAP, is unknown. Furthermore, data since then suggest that higher MAPs (eg, ≥70 mmHg) may be harmful, while targeting lower MAPs (eg, 60 to 65 mmHg) may be appropriate. Thus, a reasonable goal may be to individualize targets within a range (eg, 60 to 70 mmHg) rather than targeting one specific numeric goal. Further trials are pending that should help elucidate an optimal range for a target MAP for patients with hypotension from sepsis.
REF. UpToDate 2020.03.15
JAMA. 2020;323(10):938-949. doi:10.1001/jama.2020.0930
